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Original Article
Effect of Patient and Provider Education on Antibiotic
Overuse for Respiratory Tract Infections
Erin Chiswell  Debra Hampton  Chizimuzo T.C. Okoli
ABSTRACT
Antibiotic overuse for respiratory tract infections (RTIs) in primary care (PC) is a known important contributor to the serious health threat
of antibiotic resistance, yet remains a difficult problem to improve. The purpose of the study was to assess the effects of a combination
patient and provider education program on antibiotic prescribing in RTIs in a rural primary care clinic. Utilizing a quasi-experimental
pretest-posttest design, a retrospective electronic medical record review was conducted to determine if a patient and provider
education program changed the rates of antibiotics being prescribed (immediate or delayed) during a visit for RTI for 207 randomly
selected patients during the established evaluation time periods. The antibiotic prescription rate for the preintervention group was
56.3% compared to 28.8% for the postintervention group (p , .01). Immediate antibiotics were ordered in the preintervention group
31.1% of the time compared to 13.5% for the postintervention group (p , .05). The results of this study demonstrate that educational
interventions can be effective in rural settings and that changes in antibiotic prescribing are possible.
Keywords: antibiotic stewardship, respiratory tract infections
Introduction
Background
Antibiotic resistance is a serious health threat, and
antibiotic overuse is the single largest contributor to
the problem of antibiotic resistance.1 Each year, over
two million people in the United States get antibiotic
resistant infections and 23,000 people die from
them.2 Antibiotic resistance in common infections
that were once easy to treat is being reported at high
rates worldwide. If inappropriate antibiotic prescrib
ing does not decrease, many illnesses may soon
become untreatable.3
The most common ailment treated in primary
care (PC) is a respiratory tract infection (RTI).4
Although only approximately 10% of RTIs are
caused by bacteria, providers prescribe antibiotics
for over 60% of cases.5 According to the United
Kingdom National Institute for Health and Clinical
Excellence (NICE), "international comparisons
make it clear that antibiotic resistance rates are
strongly related to antibiotic use in PC."6 The Joint
Journal for Healthcare Quality, Vol. 41, No. 3, pp. e13-e20
(c) 2018 National Association for Healthcare Quality
The authors declare no conflict of interest.
For more information on this article, contact Erin Chiswell at erin.chiswell@
uky.edu.
DOI: 10.1097/JHQ.0000000000000144
Commission estimates that one billion dollars is
spent annually in the United States on unnecessary
antibiotics for RTIs.7
Antibiotics are not indicated in RTI because
research shows that they have not resulted in a cure
or resolution of symptoms compared to a placebo.8
Antibiotics are also associated with a significantly
higher risk of adverse reactions.8-10 There are several
factors contributing to the problem of antibiotic
overuse in RTI. Primary care providers (PCPs) indicate
that patient demand is a main reason for prescribing
antibiotics for RTIs.11-13 This demand stems from
patients' lack of knowledge about the appropriate use
of antibiotics, the appropriate treatment for viral
illness, the effective self-care regimen in RTI, and the
potential dangers of inappropriate antibiotic over
use.14 An estimated 60%-70%  of patients with RTIs
believe they need antibiotics.15 Thus, patient knowl
edge about appropriate antibiotic use is one factor that
must be addressed for this issue to improve.
Despite believing that they are not indicated,
PCPs report prescribing antibiotics for RTIs for the
following reasons: satisfying the patient, keeping the
patient in the practice, wanting to avoid being
perceived as doing nothing for the patient, lacking
the energy to resist the demand, shortening the visit
duration, and believing that patients who really want
antibiotics will obtain them anyway.13,16 This indi
cates that many PCPs lack knowledge  of  and comfort
Journal for Healthcare Quality
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Original Article
with effective strategies for reducing antibiotic
prescribing, particularly regarding patient educa
tion on the topic. When PCPs inappropriately
prescribe antibiotics for RTIs, the cycle is perpetu
ated
and
antibiotics
become
the
expected
treatment.
Research on approaches to decrease antibiotic
use in RTI  focuses on three  interventions: patient
education, PCP education, and a combination of the
two. Patient education decreases antibiotic pre
scribing in PC patients with RTIs,17-19 whereas
PCP educational interventions alone do not.9,20,21
Although patient education can come in many
forms, printed education materials have been
evaluated more than any other type. A systematic
review on the use of printed patient education
materials to reduce antibiotic prescriptions showed
that educational materials may improve patient
satisfaction and decrease reconsultation rates for
the same illness as well as for similar illnesses in the
future.18 In contrast, antibiotic prescriptions were
associated with increased reconsultation rates.18
Printed patient education materials are effective in
reducing antibiotic prescribing in RTI, even when
they are used passively.9,17-20 However, education is
much more effective when actively used by the PCP
during the patient consultation.18,20 Systematic
reviews demonstrate that the most effective educa
tional intervention for reducing antibiotic prescrib
ing for RTIs in PC is a combination of patient and
PCP education.6,9,18-20,22-24
The clinical practice guidelines (CPGs) from
NICE25 were selected as the evidence-based founda
tion for this study because this CPG and the summary
of it26 were the only current CPGs specifically
directing evidence-based management of RTI in
PC. The CPGs recommend a combined approach of
prescribing strategy and actively administered pa
tient education during the visit.25 For patients who
are not at high risk of developing complications, it is
recommended that patient education be imple
mented by the PCP and that either no antibiotics
or delayed antibiotics be prescribed.25 Delayed
antibiotic prescribing is the practice of recommend
ing no antibiotics but offering a prescription for
antibiotics that a patient may take or pick up in a few
days if symptoms worsen.25 Delayed antibiotic pre
scribing is used as an alternative to immediate
antibiotic prescribing, in which the patient is given
an antibiotic prescription to start taking immedi
ately.6 A combination of delayed antibiotic pre
scribing and patient education successfully reduces
antibiotic use in RTIs, as well as future visits for RTIs,
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May/June 2019 Volume 41 Number 3
without decreasing patient satisfaction.8,9 However,
no antibiotic prescribing results in fewer antibiotics
taken than delayed antibiotic prescribing.24
Clinical practice guidelines recommend that the
patient education accompanying delayed or no
antibiotic prescribing contains a few key compo
nents. Primary care providers should discuss the
natural history of the illness with the patient,
including how long the illness is likely to last.
Symptomatic treatment needs to be addressed.
Patients should be advised that antibiotics are not
needed, are not likely to help, and may cause
potential side effects. Primary care providers also
need to provide education on worsening or pro
longed symptoms and when to return for reevalua
tion. In addition, patients who are given delayed
antibiotic prescriptions should be instructed to take
the antibiotic only if the symptoms worsen or do not
follow the expected natural course of illness.25
Purpose
Recent studies have shown that areas with low
income and low education tend to have the highest
rates of antibiotic prescribing.26,27 Rural communi
ties are also less likely to be effectively influenced by
national prevention campaigns, which are typically
not designed specifically with rural cultural consid
erations in mind.28 Patients in rural communities
tend to have health beliefs and values that arise from
their community social norms. They value their
family members' or their own knowledge of health,
illness, and treatment based on experience. They
also see people in their community as their family.
This must be considered when designing a program
to change health beliefs and knowledge in such
a location.28,29
National media campaign efforts have failed to
make a difference in antibiotic knowledge and use in
rural areas.30 Local implementation of a program
designed with cultural considerations may be the
only way to improve the problem. Without an
effective program to improve antibiotic prescribing
in RTI, the cycle of inappropriate antibiotic demand,
prescribing, and use was likely to continue perpetu
ating itself, leading to a worsening in antibiotic
resistance. In a rural community, an education
program must be specifically designed to reach that
specific population and address changing their social
norms.28 The purpose of this study was to evaluate
the effect of a combination patient and provider
education program on reducing immediate antibi
otic prescribing in RTIs in a rural setting PC clinic.
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Page 3
Methods
Design, Data Collection, and Ethical Approvals
Using a quasiexperimental pretest-posttest design,
antibiotic prescription data were obtained via
a retrospective electronic medical record review of
patient records that were evaluated by a full-time
"walk-in" care provider 1 year prior to and 1 year
after program implementation. No additional bal
ancing measures were specifically examined. Pro
vider education was done after all preintervention
group patients had been seen in the clinic and
before data collection occurred for the postinter
vention group; all providers were educated during
the same 1-month time period. The Institutional
Review Board, Protocol Number 16-0609-X3B,
approved the study.
Setting and Sample
The study was conducted at a rural PC practice
setting in the south central part of the United States
that provides care for patients of all ages. The
population for this study consisted of "walk-in"
patients, age 2-65, evaluated by the participating
providers and diagnosed with RTI. Exclusion criteria
included the following: additional diagnosis of
bacterial illness in the same visit (such as pneumonia
or sinusitis); duration of illness: 10 or more days;
comorbidities of: COPD, asthma, or immunosup
pression. These exclusion criteria were based on the
CPG indicators for patients at higher risk for
complications and an immediate antibiotic regimen
could be considered appropriate for these patients.6
There were 1,943 patients who met the initial
inclusion criteria, 1,075 in the preintervention
group and 868 in the postintervention group. A
power analysis was done to determine the number of
participants needed in each group to obtain
a statistically significant change; the analysis demon
strated that at least 103 needed to be in each group.
Through a random selection process using the 1,943
patient records, the first participants on the list in
each sample group to meet all inclusion and
exclusion criteria were selected as the sample. Fifty-
one of the records reviewed for inclusion had to be
excluded, primarily due to comorbidities and
duration of illness of 10 days or longer, making
them potentially at higher risk for complications and
appropriate candidates for possible antibiotic treat
ment. Data were collected on a total of 207
participants, 103 in the preintervention group and
104 in the postintervention groups.
Journal for Healthcare Quality
Interventions
The patient education intervention program, as shown
in Table 1, was implemented over 1 year in accordance
with the CPG recommendations6 regarding the
education that all RTI patients should receive. Patient
education included content designed to address the
values and beliefs of this population, enabling this new
health information to have high compatibility with the
needs of this community. Patients were given  repeated
exposure to health information in the form of posters
and handouts. Some patients were given prescriptions
for delayed antibiotics, which allowed them to still
receive an antibiotic prescription and determine for
themselves if they needed to take it, allowing them to
trial the intervention.
During the visit, providers educated patients about
RTIs, natural history of illness, expected duration
and symptoms, symptomatic treatment, and abnor
mal symptoms for which they should return. Pro
viders also discussed that antibiotics would not help
and would potentially harm. They provided this
education using plain language, which was rein
forced with a handout, as shown in Table 1.
Posters were obtained and displayed in the clinic
from the Centers for Disease Control and Prevention's
"Get Smart: Know When Antibiotics Work" campaign31
(recently renamed "Be Antibiotics Aware: Smart Use,
Best Care"32 with updated posters that contain similar
messaging), as shown in Table 2. According to CPG, the
participating "walk-in" care providers were educated on
actively teaching patients about RTIs and appropriate
antibiotic use during the patient visit, as well as on the
use of no or delayed antibiotic prescriptions.6
Results
Demographics
The 207 participants were comprised of 138 females
and 69 males, as shown in Table 3. Of the
participants, 79.2% (n 5 164) were adults, age
18-65. Adolescents, age 11-17, comprised 14.5%
(n 5 30) of the participants, and children, age 2-11,
comprised the remaining 6.3% (n 5 13). There were
103 participants in the preintervention group and
104 in the postintervention implementation group.
There was no difference in age (p 5 .24) or gender
(p 5 .92) between the two groups.
Data Analysis and Findings
In the preintervention group, 103 participants were
evaluated for RTI. Fifty-eight of them were pre
scribed antibiotics for an antibiotic prescription rate
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Original Article
Provider Education to Patient During Visit:
-  A respiratory tract infection, or "the common cold," is usually caused by a virus.
-  Antibiotics do not treat viruses; they treat bacteria.
-  Viruses have to go away on their own.
-  Taking antibiotics for viral illnesses can cause dangerous problems, like serious side effects or reactions and put you at risk for an infection that
is resistant to treatment.
-  Symptoms (like cough and congestion) usually last 1 to 2 weeks.
-  Symptomatic treatment encouraged; specific recommendations made as appropriate to the patient.
-  High fevers, shortness of breath or worsening after a period of improvement are not a normal part of this illness and if you experience these,
you should be reexamined.
Reinforced with handout:
-  Written in plain, lay language using terms that patient population understands.
-  Addressing main points contained in provider education.
-  Recommending symptomatic treatments according to symptom, age, and comorbidity (such as hypertension).
-  Addressing frequently asked questions and commonly held beliefs from our patient population, such as why they should not to take an
antibiotic now and why yellow or green nasal drainage does not always mean an antibiotic is needed.
Table 1. Translating Important Information Into Effective Patient Education
in RTI of 56.3%. In 32 of those 103 encounters, the
antibiotic prescriptions given were immediate for an
immediate antibiotic prescribing rate of 31.1%. In
the postintervention group, 104 participants were
evaluated for RTI. Antibiotics were prescribed in 30
of the 104 encounters for an antibiotic prescription
rate of 28.8%. There was a significant decrease in the
number of antibiotics prescribed in the postinter
vention group in comparison with the preinterven
tion group (x 2 5 15.97, p , .001). In the 104
postintervention group encounters, only 14 were
given immediate antibiotic prescriptions for an
immediate antibiotic prescription rate of 13.5%.
The number of immediate antibiotic prescriptions
CDC's "Get Smart: Know When Antibiotics Work" Campaign Postersa displayed containing these points:
-  Taking antibiotics when you have a virus (like a cold or the flu) will NOT:
s Cure the infection
s Help you feel better
s Keep you from spreading the infection to others
s Help you get back to work faster
-  Antibiotics are only needed for treating certain infections caused by bacteria; antibiotics do not treat infections caused by viruses.
-  Taking antibiotics for a virus puts you at risk for a bacterial infection that is resistant to antibiotic treatment.
a This campaign from the CDC has recently been renamed "Be Antibiotics Aware: Smart Use, Best Care"32 with updated posters that contain similar
messaging.
Table 2. Simply Getting the Message Across31
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Page 5
Characteristics
Preintervention
group (%)
Postintervention
group (%)
Gender
Male
33
33.7
Female
67
66.3
Age
Child (2-10)
4.9
7.7
Adolescents
(12-17)
12.6
16.3
Adults (18-65)
82.5
76
a Additional information was not collected due to the homogeneity of the
patient population.
Table 3. Characteristics of Participants by
Groupa
decreased significantly in the postintervention group
in comparison with the preintervention group (x 2 5
9.28, p , .05). There was no significant change in the
number of delayed antibiotic prescriptions after
implementation of the intervention (p 5 .08).
A chi-square test was used to determine whether
there was an association between antibiotic pre
scribing and gender. No difference was found in
relation to the gender of participants and antibiotic
prescribing rate in the preintervention group (p 5
.95), postintervention group (p 5 .38), or overall
(p 5 .62). A Mann-Whitney U test was used to
determine whether there was an association be
tween antibiotic prescribing and age. There was
a significant difference in antibiotic prescribing
between age groups in the preintervention group;
adults, age 18-65, were significantly more likely to be
prescribed an antibiotic (p 5 .012). However, there
was no significant difference in antibiotic prescrib
ing between age groups in the postintervention
group (p 5 .29).
Limitations
This intervention was conducted in only one clinic.
Furthermore, only the "walk-in" area of that clinic was
involved, not the entire clinic. Because of the
retrospective design of the study based on existing
medical records, the number of variables for analysis
was limited. Moreover, by measuring only two time-
points, the sustainability of the effect of the program
cannot be demonstrated.
Journal for Healthcare Quality
Only full-time providers that saw patients in the
walk-in portion of the clinic were participants for this
study; part-time and per diem providers and full-time
providers who saw patients by appointment and
focused more on preventative care and chronic
disease management do not see many patients with
RTI and were therefore excluded. The providers who
participated did so voluntarily because they had
noticed a problem and wanted a change. Providers
who voluntarily opt to become involved in a study of
this nature may be those who are willing to attempt
changes in prescribing habits more readily than
other providers. This may also limit the generaliz
ability of the study findings.
Discussion
The number of immediate and total antibiotic
prescriptions for RTIs decreased significantly after
the implementation of the combination education
initiative. Reduced use of antibiotics when not
indicated is the ultimate goal. Although delayed
antibiotic prescriptions resulted in less antibiotic use
than immediate prescriptions, not prescribing an
antibiotic at all has been demonstrated to result in
less antibiotic use than delayed prescriptions.24 Since
the overall goal for implementing the program was to
reduce antibiotic use in patients with RTI, decreasing
antibiotics overall is a step toward that overall goal.
Immediate antibiotic prescription change was cho
sen at the outset of the program as the outcome
measure, rather than overall antibiotics, because it
was considered a more achievable goal in this patient
population. Delayed antibiotic prescriptions was
selected as a substitution while the patients became
exposed to new knowledge and PCPs became more
comfortable educating patients, until patients and
PCPs became comfortable enough to utilize the no
antibiotic strategy.
The number of delayed antibiotic prescriptions
did not change significantly which indicates that
delayed antibiotic prescriptions were not frequently
utilized as a substitution for immediate antibiotics in
the postintervention period. Much of the literature
focuses on interventions and their impact on
improving antibiotic prescribing overall and/or
guideline adherence. There is minimal information
in the literature about the impact of an educational
program on the outcome of immediate or delayed
antibiotic prescription. Delayed antibiotic prescrip
tions have been utilized as a method to decrease
antibiotic prescriptions and have been included in
studies as actions of guideline adherence. More
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Page 6
Original Article
studies are needed to further understand the
educational approaches that may enhance delayed
antibiotic prescribing.
Rural populations, particularly those with low
socioeconomic status, tend to have low antibiotic
knowledge and high antibiotic use.30 Educational
programs have been shown to decrease antibiotic
use in RTI; however, there is a gap in the literature
regarding implementation of these programs in
rural populations. Knowing that rural populations
have specific cultural and community needs re
lated to health beliefs,28 implementing educational
programs in other rural settings may not result in
generalizable findings. This study demonstrates
that a combined patient and provider education
program, tailored to the needs of the rural
population, can produce improvements in antibi
otic prescribing like those demonstrated in other
populations.
As noted earlier, PCPs listed concerns about
patient satisfaction and retention as reasons for
prescribing antibiotics for RTIs. Additionally, with
the implementation of value-based purchasing,
PCPs and organizations may resist antibiotic stew
ardship initiatives out of concern that they may
decrease patient satisfaction. The findings of this
study may help overcome some of the initial
resistance to antibiotic stewardship initiatives and
increase support for them.
The overuse of antibiotics in RTI, perpetuated by
the cycle of patient demand and PCP prescribing,
may seem challenging to change. Yet, the results of
this study support to those of others18,20,22-24 that
educational interventions with providers and patients
can result in change and reductions in antibiotic
prescribing for RTIs can be achieved.
Conclusion
Although information on the dangers of antibiotics is
widely published and prescribers are continually
urged to prescribe antibiotics judiciously, this study
illustrates the complexity of the issue and the
continued need for improvement. Significant reduc
tions in immediate antibiotic and overall antibiotic
prescriptions were observed. Changing antibiotic pre
scribing involves changing the beliefs and behavior of
patients and providers, which can seem daunting and
unachievable. The importance of these study results is
that they demonstrate to practitioners that changes in
antibiotic prescribing are possible, through educa
tional interventions, even in settings that may seem
challenging due to patient knowledge and established
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May/June 2019 Volume 41 Number 3
provider prescribing patterns. Simple, educational
interventions, such as posters, patient handouts, and
delayed antibiotic prescriptions can make a difference.
For practitioners, the key is to be reminded that
antibiotic stewardship is possible and to take that first
step toward making a change. Hence, this study's
findings can be used as a source to change PCP
practice and to develop interventions to further
promote antibiotic stewardship.
Implications
Antibiotic prescribing can be changed through very
simple interventions, even in settings and popula
tions where the cycle of antibiotic overuse, patient
demand, and provider prescribing seems impossible
to break. Educational interventions, when tailored
to the needs of the population, can produce positive
changes in rural settings. Small, low-cost, simple to
implement educational interventions do work.
Displaying posters from the CDC's "Be Antibiotics
Aware" campaign32 in patient exam rooms can be
the simple step that begins this change by passively
exposing patients to this knowledge. Patient hand
outs that are specific to the patient population can
be very effective in providing education, giving
reassurance, answering frequently asked questions,
guiding supportive care, and advising about return
visits. Delayed antibiotic prescribing can be used as
a progressive step toward decreasing antibiotic
prescriptions until providers and patients are more
comfortable with no antibiotic prescriptions.
Further research on the impact of an educational
program on these outcomes may be beneficial, as well
as on factors associated with uptake of or resistance to
utilization of delayed antibiotic prescriptions used in
substitution for immediate antibiotic prescriptions. In
practices such as this one, where educational programs
have shown some improvement, it could be beneficial
to explore the reasons why delayed antibiotic pre
scriptions did not change significantly. Knowing the
influential factors that persist after the implementation
of evidence-based practice educational programs
could help target more successful interventions for
future programs.
Follow-up studies would be beneficial to de
termine whether the improvements in antibiotic
prescribing are sustained and whether continued
replication results in successful dissemination
throughout the entire office. Additionally, further
exploration of whether this project had any impact
on reconsultation rates, or the frequency with which
patients returned for additional visits for the same
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Page 7
or similar illnesses and patient satisfaction scores,
would be beneficial.
After conducting this study and finding that the
results support the findings of other studies, a new
question has moved to the forefront. If we know
what works, why are not we implementing this in
practice? The question is, with the knowledge that
patient and provider educational programs are
successful in improving the problem of antibiotic
overprescribing, why are not these educational
programs more widely implemented? What are the
barriers to implementation and how can they be
overcome? Further research in this direction would
be beneficial to achieve more implementation; now
that success is fairly established but provider buy-in
remains limited.
Authors' Biographies
Erin Chiswell, DNP, APRN, FNP-C, is a Lecturer at the University of
Kentucky College of Nursing, Lexington, KY and practices as an APRN in a rural family
practice office.
Debra Hampton, PhD, RN, FACHE, NEA-BC, is Academic Coordinator,
Executive Nursing Leadership and MSN to DNP Programs and  at
the University of Kentucky College of Nursing, Lexington, KY.
Chizimuzo Okoli, PhD, MPH, RN, CTTS, is Director of Evidence Based
Practice at Eastern State Hospital and an Associate Professor at the University of
Kentucky College of Nursing, Lexington, KY.
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